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目的本文着重分析医院病案数据的重要性:病案数据功能的拓展,在医学科研中的作用,在疾病预防和统计中的应用,在医院管理中的作用,如医院发展分析、医院医疗技术水平分析、医院各科考核排名分析、医院成本核算、医院费用结算、医疗付款方式、单病种监控、医院营销等方面的分析、引出优质存储病案的必要。方法通过对比分析电子病案和纸质病案数据,存储和流通方式现状,寻找出纸质病案和电子病案内容不一致、归档病案数据缺陷、不完整、错误的原因和危害。结果规范病案数据收集保证医疗统计数据准确,主要在于加强电子病案和纸质病案的管理,分析内容不一致、归档病案数据缺陷、不完整、错误的成因和对策,做好病案质量审核,强化发展和应用电子病案信息系统。结论转变观念,加强纸质病案和电子病案的同期管理,开发利用病案统计信息,强化病案管理中的法律意识,使电子病案与纸质病案具有同等的法律效力。
The purpose of this paper is to analyze the importance of hospital medical record data: the expansion of medical record data function, the role in medical research, the application in disease prevention and statistics, the role in hospital management, such as hospital development analysis and hospital medical technology level analysis , Analysis of hospital rankings examination, hospital cost accounting, hospital fee settlement, medical payment mode, single disease surveillance, hospital marketing and other aspects of analysis, lead to the need for quality storage of medical records. Methods By comparing the electronic medical records and paper medical records data, storage and circulation status, find out the inconsistency between the paper medical records and the electronic medical records, the defects, incomplete, the wrong causes and the hazards of the filed medical records data. Results Standard medical records data collection to ensure accurate medical statistics, mainly to strengthen the management of electronic medical records and paper medical records, analysis of inconsistencies, the filing of medical records data defects, incomplete, wrong causes and countermeasures, good medical record quality review, and strengthen the development and Application of electronic medical record information system. Conclusions Changing concepts, strengthening the simultaneous management of paper medical records and electronic medical records, developing the use of medical records statistical information, and strengthening the legal awareness in medical records management make the electronic medical records and paper medical records have the same legal effect.